Learning together to safeguard children: developing a multi-agency systems approach for case reviews

Introduction - Why do we need new methods of learning?

The findings of serious case reviews (SCRs)
and public inquiries tend to be familiar and
repetitive, raising questions about their value
for improving practice.

Similar circumstances in engineering, health
and other high-risk industries led to the development
of the ‘systems approach’.

This gets to the bottom of why accidents occur
and so allows for more effective solutions.

Academics have demonstrated that the approach
also works for the field of safeguarding and
protecting children in
theory. To work in practice,
the approach needed to be tested out and adapted.

To date our most public way of learning has been
through the investigation of the death of a child
from child abuse or neglect. In the UK, as in many
other countries, these serious case reviews (SCRs)
or public inquiries have been a major influence
on the way services have developed (Parton, 2003;
Stanley and Manthorpe, 2004; Parton, 2004). However,
their value has been increasingly questioned as
it has become apparent that they regularly identify
the same problems in frontline practice and make
similar recommendations (e.g. Dale et al, 2005;
Rose and Barnes, 2008).

This situation is remarkably similar to the experience
of accident inquiries in other sectors such as
aviation and health. In those fields steps have
been taken to improve matters through the development
of the systems approach. This looks for causal
explanations in all parts of the system. Rather
than stopping once faults in professional practice
have been identified, the systems approach explores
the interaction of the individual with the wider
context to understand why things developed in
the way they did.

Social work academics have argued the need to
appropriate this method in theory (e.g. Munro,
2005; Lachman and Bernard, 2006) but almost no
research has been conducted on the feasibility
of such a move. The Victoria Climbié tragedy
underlined the urgent need to explore alternative
approaches. Consequently, SCIE decided to try to
adapt the model for child welfare work.

The basics of the approach

The goal of a systems
case review is not limited to understanding why
specific cases developed in the way they did,
for better or for worse. Instead, a case is made
to act ‘as a “window” on
the system’ (Vincent, 2004: 242). It provides
the opportunity to study the whole system, learning
not just of flaws but also about what is working
well.

The cornerstone of the approach is that
individuals are not totally free to choose between
good and problematic practice. The standard of
their performance is influenced by the nature
of

the tasks they
perform

the available tools designed to support
them

the environment in which they operate.

The
approach, therefore, looks at why particular
routines of thought and action take root in multi-agency
professional practice. It does this by taking
account of the many factors that interact and
influence individual worker’s practice.

Ideas
can then be generated about ways of re-designing
the system at all levels to make it safer. The
aim is to ‘make it harder for people to
do something wrong and easier for them to do
it right’ (Institute of Medicine, 1999:
2).